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Mindfulness-Based Stress Reduction (MBSR) Tools

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MBSR Tools

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Questionnaire

Thank you for filling this out at the start of the program. I realize the personal nature of these questions. Please be assured that completed forms are kept in strict confidence.

Thank you for your response. ✨

Name(required)

Email(required)

Student ID Number (all identifying info will be removed later)

What is your main reason for participating in MBSR?

What do you care about most?

What gives you the most pleasure in your life?

What are your greatest worries?

Please list three personal goals you have for taking the MBSR Program

Are you currently engaged in psychotherapy?

If not, have you been in therapy during the last three years?

Any Psychological hospitalizations? If so, when?

During the last MONTH have you…

Considered Suicide?

Yes

No

Sought psychiatric help?

Yes

No

Had thoughts of death or dying?

Yes

No

Had urges to beat, injure, or harm someone?

Yes

No

Had urges to smash or break things?

Yes

No

Had spells of terror or panic?

Yes

No

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